MENSTRUATION MATTERS

The Disappearing Diaphragm

Did you know that last year’s combined sales of Yaz and Yasmin, the most popular oral contraceptives in the U.S., totaled $1.64 billion? Did you know the drugs are also the target of 1,100 lawsuits for potentially fatal blood clots? Did you know that an estimated 50 women have died from taking those contraceptives?

Despite such health risks, however, oral contraceptives remain an extremely popular method of birth control in the U.S., second only to sterilization. The Guttmacher Institute reports that whether a woman prefers the Pill or sterilization is largely a function of age, with women under 30 choosing the Pill and women over 30 choosing permanent methods. These trends have been fairly stable since 1982.

None of these facts surprised me as much as the news that fewer than one percent of women in North America (and northwestern Europe) use the diaphragm–or any other woman-controlled barrier method. I’m puzzled that a safe, reliable, fairly easy-to-use (with some training and practice), inexpensive method of controlling fertility is not more widely recommended. Used correctly and consistently, the diaphragm has an effectiveness rate of 94 percent. Nevertheless, diaphragm use declined after the Pill was introduced, from 25 percent of married women in 1955 to 10 percent in 1965, and kept dropping thereafter, to just 4.5 percent of all women in 1982 and 0.2 percent today, according to the CDC [pdf].

U S. Medical Eligibility Criteria for Contraceptive Use, 2010, released last month by the Centers for Disease Control, shows that the diaphragm has no medical contraindications for most women. The exceptions are latex allergies, immediate postpartum or post-termination use, uterine prolapse, and women with HIV/AIDS, for whom the risk is not the diaphragm itself but the accompanying spermicide nonoxynol-9, which may increase viral shedding and HIV transmission to uninfected sex partners.

Yet the American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice recommends that hormonal methods such as IUDs or injections be offered as “first-line contraceptive methods and encouraged as options for most women.” At this year’s annual ACOG meeting last month in San Francisco, the group issued a press release with eight gushing statements of praise for the Pill on its 50th anniversary. (See re:Cycling‘s response to the ACOG statement here.)

But nearly four of every ten women who use contraceptives are not satisfied with their method, and I hear frequently from young women that they’re pressured at college health centers and physicians’ offices to choose hormonal methods, usually the Pill, over barrier methods such as condoms and diaphragms. Even after negative experiences with the Pill, women are often encouraged to try another brand rather than another method.

I’ve even heard of educators and health care providers actively discouraging use of the diaphragm because “it’s messy”. This complaint baffles me, and I used a diaphragm for 15 years. With or without a diaphragm, sex is messy.

Although diaphragms must be accurately fitted by a health care professional and re-assessed every few years, they remain cheaper than hormonal methods and require less frequent physician visits. A diaphragm can be inserted hours or moments before intercourse, and it is a fully reversible, female-controlled method of birth control. There is some evidence that diaphragm use minimizes women’s exposure to certain STIs , and ongoing research by pharmaceutical companies is aimed at developing a spermicide that is also antimicrobial.

There’s even research on a one-size-fits-all diaphragm in progress: Program for Appropriate Technology in Health (PATH) has developed and patented a single-size diaphragm designed to fit most women comfortably. The modified device has proven effective in initial studies, and the organization plans to apply to the FDA for approval as a contraceptive by the end of next year.

Early last century, Margaret Sanger risked prison to introduce the diaphragm to an American public desperate for effective birth control. We need a contemporary crusader to re-introduce the diaphragm in the 21st century for those seeking safe, effective, hormone-free birth control.

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8 Comments

I’ve recently hit menopause, but I used a diaphram all my reproductive life. I really liked using a form of birth control that I only used when I was going to have intercourse, not like the pill or an iud that would affect my body all the time.

I notice that my daughter is much more scared of a pregnancy due to birth control failure, in fact she and her boyfriend were at least talking about using the pill plus condoms. I always felt that the risk of failure of the diaphram was acceptable, and I never did have a failure. When I decided to have my first child, at age 34, I got pregnant my first month not using the diaphram.

As the diaphram became less used, I had some funny experiences. I went for a mammogram and answered a question that yes I used birth control. The nurse asked me something about the pill and I said I didn’t take the pill. She said “I thought you said you used birth control.” Even my gynecologist didn’t keep a diaphram fit kit handy, but I would just bring mine to my checkup and she would check the fit.

Laura Wershler
on June 24, 2010 at 9:11 pm

I don’t get it either, Liz. The single most recognizable sexually assured pop culture heroine of our time, Carrie Bradshaw, used a diaphraghm. You’d think that alone should have raised it’s popularity. I’ve got tons more to say about this issue, tomorrow. Its time to take sexual health care providers to task for being so biased about what does and what does not constitute effective, appropriate birth control.

Tori
on June 25, 2010 at 12:03 am

The exceptions are latex allergies…

Which is still not a contraindication — I’m guessing — for silicone diaphragms, like mine is.

In Canada, the company who manufactures the contraceptive goop (technical term) you need to use a diaphragm has decided it’s not worth their while to make it any more.

I’ve used a diaphragm as my primary form of contraception for over 20 years. My doc refuses to fit them, I have to go to a colleague within his family practice to have it done. And now I can’t even buy the supplies I need to use it. There’s a local clinic who import it, I’ve learned.

And I’ve had the same reaction from medical professionals who use “are you using birth control” to be synonymous with “are you using hormonal contraception”.

As I said at the cross-post at the Ms. blog, this is a very interesting post. Just
FYI, Margaret Sanger was a key supporter of the research on the first oral
contraceptive pill and secured funding from her friend Katherine McCormick
when no one else would touch this research (even drug companies).

Elizabeth Kissling
on June 25, 2010 at 2:21 pm

Thanks for commenting, Pam. I never had a failure, either, or even a pregnancy scare. In the comments at Ms. Facebook posting, there’s lots of fretting about effectiveness rates, but if you USE IT EVERY TIME, the diaphragm is very effective! Most (admittedly not all) of diaphragma failures can be attributed to failure to insert the darned thing.

Laura, that’s an excellent point! Look at what Carrie Bradshaw did for cosmopolitans and Jimmy Choos. Why no SATC effect on the diaphragm??

Tori – that’s correct. As with the Keeper/Diva Cup, silicone versions are great for those with latex allergies.

Chris, that’s just staggering! The spermicide is not available in all of Canada, or just BC? Do I need to start sending you black market contraceptives from the U.S.?

Thanks for commenting again, Knitting Clio. I’m aware of that history of pill research and funding. The PBS series “American Experience” featured an excellent film on the history of the pill a few years ago that tells that story in a compelling way. I’ve found it great to show in classes.

Speaking of docs, I attended a sexuality conference last week in Guelph, ON. I went to the Contraceptive Update session which as usual was skewed towards hormonal contraception, as is usual. However, the OBGYN who did the session spoke about the diaphragm as an effective and under utilized method. GOOD. But when I asked about barriers to access re: finding a doc to fit one, finding a pharmacy to sell you one, and finding contraceptive gel to make it effective, she was oblivious. Even though she fits and prescribes, though rarely, she still thought the spermicide came with the diaphragm. How discouraging is that?

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We are researchers in the social sciences, the natural sciences and the humanities, health care providers, policy makers, health activists, artists and students from a wide range of fields with interests in the role of menstrual and ovulatory health across the life span.